7/28/2019 54.1Andrew

1/5

CJOT Vol. 54 No. 1

The Occupational The! ipist's Tthe Management f DiabetesMavis Andrew

AbstractThis paper will describe the Diabe-tic Day Centre program at theLions Gate Hospital, and theoccupational therapist's unique rolein that program. Diabetic processesor characteristics which influenceassessment and intervention by re-habilitation personnel will be dis-cussed, as well as lifestyle manage-ment techniques which promote thepatient's physical and psychologicalwell-being. Adaptive equipmentavailable for managing medicationswill be reviewed.

Mavis A. Andrew, B.Sc.O.T., is StaffOccupational Therapist at the LionsGate Hospital, North Vancouver,British Columbia.

Since the discovery of insulin sixtyyears ago, profound changes havetaken place in the history of diabetesin man. For instance, long-term sur-vival of people with diabetes is nowthe rule. As a result, the problemsof retinopathy, neuropathy, myocar-dial and cerebral infarction, andamputations have assumed primaryimportance in clinical management.Ross, Bernstein, and Rifkin (1983)revealed that diabetes is the leadingcause of new cases of blindness. Dia-betics have a 25 times greater chanceof developing blindness, a 20 timesgreater incidence of renal disease,and a significantly greater risk ofmyocardial infarction and amputa-tions. When working with patientshaving a primary or secondary diag-nosis of diabetes, it is important tobe aware of the physiologicalproperties of diabetes and how theseinfluence the patient's treatmentprogram.

Description of DiabeticDay CentreThe Diabetic Day Centre is partof the Medical Day Centre of theLions Gate Hospital in North Van-

couver. The philosophy of the Medi-cal Day Centre is to serve the needsof the population for care and healthon an ambulatory care basis (PolicyManual, 1984). Programs are estab-lished to provide an effective andeconomical alternative to in-patientcare, reduce the number of patientadmissions, and provide preventivemedicine education.

The goal is to assist clients andtheir families in initiating and/ormaintaining a day-to-day programof self-directed diabetes manage-ment which will result in fewer inter-ruptions of a normal lifestyle and

fewer hospitalizations due to com-plications (Diabetic Day CentreManual, 1984).

The objectives include:1) enabling the newly diagnosedclient with diabetes to build a

sound approach to living withhis condition.

2) altering and rebuilding themanagement program for thediabetic who has problemsmanaging his diabetes.

3) educating the client who hasdiabetes as a secondary prob-lem in the management ofcoping with the disease.

4) increasing the health profes-sional's ability to understandthe condition in order thathe/she may participate effec-tively and knowledgeably inthe educational program.All the clients must be referred by

their family physician. They includeinsulin dependent (Type I) and non-insulin dependent (Type II) diabe-tics. All age ranges from pediatricsto geriatrics are accepted, with spe-cial Children and Teenagers Days.

The team members consist of thefollowing:Clinical Director (Internist specia-

lizing in diabetes)Diabetic Nursing InstructorDietitianRehabilitation Therapists (Occu-pational Therapist and Phy-

siotherapist)PharmacistSocial WorkerPodiatristCounselling topics include:1) disease processes or complica-tions of diabetes2) home medication and glucose

monitoring systems

February/Fvrier 1987 1

7/28/2019 54.1Andrew

2/5

CJOT Vol. 54 N o. 13) diet management4) psychosocial counselling5) exercise lifestyle counselling6) skin care managementThe clients attend the DiabeticDay Centre for a full day, beginningat 7:00 a.m. with a fasting blood

sugar test. They attend lectures onthe above topics. Clients receive die-tetic breakfast and lunch while at theCentre, and the program is complet-ed at 3:00 p.m.

The OccupationalTherapist's Role in theDiabetic Day Centre

The occupational therapist's goalis to counsel diabetic c li ents andtheir families on the way activity andrecreation affect the control of dia-betes, and thereby ensure the maxi-mization of activities of daily living.

The objectives are:1) to discuss the role of exerciseand activity in diabetic controland its effect on blood sugarlevels;2) to discuss how stress affects

blood glucose levels;3) to provide counselling for spe-cific problems (e.g. poor circu-

lation to the feet, explanationof the rationale for and ex-amples of foot and ankle exer-cises, and description of ap-propriate footwear);

4) to give recommendations ofsuitable community resources(e.g. senior citizen facilities,adaptive fitness classes, or fur-ther stress managementcourses);

5) to involve the clients in apractical activity sessionwhich is geared towards theages and needs of the group(e.g. doing cha ir exercises or anaerobic session).

The occupational therapist worksin the Diabetic Day Centre one hourper program day. The patients, seenon a group basis, are lectured on theabove topics, and then led in an

exercise/activity session. The lectureis done in an informal manner, usinga blackboard as a visual aid. Groupdiscussion is promoted throughout.Recommendations made must beappropriate for the type of clientsin the group. When presenting to agroup of Type II (non-insulindependent) diabetics, usually geria-trics, it is important to acknowledgeother disorders they may have suchas arthritis, cardiac conditions, etc.which may in f l uence recommen-dations on suitable community re-sources. Similarily, with the Type I(insulin dependent) diabetics, it isimportant to consider how insulininjections may affect their lifestyleand choice of leisure activity.

Complications ofDiabetes Which AffectTherapeutic Managem entDue to the complex nature of the

disease process of diabetes there areseveral complications which affectthe therapeutic management of aclient who has diabetes. The follow-ing factors apply to a rehabilitationpatient population with primary orsecondary diagnosis of diabetes.

a) Treatment activity programs.Treatment activity programs

should be geared to the client's dailyenergy expenditure at home, workand leisure. The basis of this princi-ple is that exercise leads to a decreasein blood glucose levels (Vranic,Kemmer, Berchtold & Berger, 1983).Since blood glucose is absorbedmore readily when muscles are con-tracting rather than when the mus-cles are at rest, blood glucose levelsfall during exercise. In view of thisfactor, the diabetic should exercisefollowing a meal when his bloodsugar levels are high, rather thanbefore a meal when his blood sugarlevels are low. Additionally, theamount and type of treatment oractivity should reflect his/her dailyenergy expenditure.

Exercise has several other impor-tant effects on diabetic management,

such as enhancement of the cardio-vascular system, weight control, andstress management (Andrew, 1985;Cantu, 1980; Jette, 1984; Schumann,1983; Vranic, Horvath, & Wahren.1978; Vranic, et al. 1983). Unfortu-nately, they are beyond the scope ofthis paper.

In the diabetic, there are two con-ditions of sugar imbalance whichwould affect performance, and theseare monitored during treatment ses-sions. These imbalances are insulinreaction or hypoglycemia andhyperglycemia. Insulin reaction orhypoglycemia is a dangerous lower-ing of the blood sugar levels. Itusually has a rapid onset, and canbe caused by:

1) excessive insulin dosage,2) postponing or omitting meals,or3) unusual physical activity(Ranch & McWeeny, undat-ed).Symptoms include: fatigue, ma-

laise, headache, drowsiness, pallor,sweating, nervousness, trembling, orunusual behaviour. Treatment is toingest food having high sugar con-tent that is readily digested, such asorange juice, or dextrose tablets,which diabetics frequently carry.

Hyperglycemia, which developsmuch more slowly than hypoglyce-mia, occurs when there is an increasein blood sugar levels. Causes ofhyperglycemia include:

1) inadequate insulin therapy,2) infections, or3) excessive food intake (Ranch& McWeeny, undated).The symptoms may include: ex-cessive urination, thirst, weakness

and fatigue, visual disturbances, orelevated blood glucose readings.Control is restored by balancingfood, exercise, and medication. Pro-longed hyperglycemia requires me-dical investigation and treatment.

b) Peripheral NeuropathyPeripheral neuropathy involvessegmental demyelination of the

12 ebruary/Fvrier 1987

7/28/2019 54.1Andrew

3/5

CJOT Vol. 54 No. 1

peripheral nerve fibers. Nerves mostcommonly affected are the peroneal,femoral, tibial, ulnar, and mediannerves (Brown & Towne, 1977). Themost common clinical signs are diffi-culty with gait or upper extremityfunction, such as manipulating but-tons, loss of deep tendon reflexes,muscle atrophy, and cramps.Occupational therapists can provideactivities of daily living retrainingand/or appropriate aids, andstrengthening and dexterity activi-ties. Examples of strengthening anddexterity activities are thera-puttyexercises, manipulation of velcroHi-Q game markers, clothes pegs,button boards and wood workprojects. The therapist may alsochoose to give the patient a set ofexercises which he can do at homeupon discharge. If the skin is in poorcondition, then the activities chosenmust not be irritating or cause fur-ther skin breakdown.It has been shown that throughappropriate diabetic management,accompanied by therapeutic exer-cises, there may be a decrease in thesymptoms of the peripheralneuropathy and an actual improve-ment in the patient's functional abil-ity. However, the actual nerve de-myelination seen in peripheralneuropathy may or may not be re-versible with appropriate diabeticmanagement (Ellenberg, 1983).

c) Decreased SensationPeripheral neuropathy or a poorcirculatory system may lead to pe-ripheral loss of sensation (Browne

and Towne, 1977). Loss of peripheralsensation leaves the diabetic vulner-able to skin breakdown, and under-lines the development of neuropath-ic ulcers and Charcot joints(Ellenberg, 1983). It is important tocheck the skin condition particularlyon the feet, to educate the patienton skin care principles, to assess thepatient's ability to do proper footskin care, and to educate on neces-sary aids or adaptations or educatecare givers on these techniques. Gos-sage (1984) outlines the specifics offoot care. Upon observation ofpotential problems such as callouses,corns, and ingrown toenails, it is

important for the therapist to pointthis out to the patient, and to thenursing staff who can then initiatea podiatrist consultation.Additionally, the occupationaltherapist should assess and makerecommendations on footwear for

the diabetic. The therapist shoulddetermine the type of floor surfacethe patient will encounter most fre-quently, the amount of walking thepatient will be doing upon discharge,the type of fastener the patient isable to manipulate, and the weatherconditions the footwear will be usedin.

When working with a patient whohas a primary diagnosis of cerebralvascular accident (CVA) or lowerextremity amputation, the therapistshould discuss the client's ambula-tory status with the physiotherapist.For example the CVA client mayrequire an ankle/foot orthosis; theamputee may require a prosthesis.Considering these factors, the thera-pist should advise the patient onappropriate footwear and where itcan be purchased.

d) Fat MetabolismInsulin also affects fat metabolism

(Guyton, 1982). Extreme arterio-sclerosis can often lead to heart at-tacks, cerebral vascular accidents,and peripheral vascular disorders,which are the primary conditionsrelated to altered fat metabolism indiabetics. When treating a diabeticpatient who has one of the abovediagnoses, it is important to be awareof how activity affects diabetes con-trol. Similarily, when treating a pa-tient in the advanced stages of dia-betes, it is important to find out thepatient's cardiovascular status andnot overstress this system.

e) RetinopathyRetinopathy involves a processwhereby the capillaries in the retinadevelop micro-aneurysms. Thisprocess may eventually lead toblindness. Treatment includes good

diabetic management and lasertherapy (Nemchik, 1983). Therapeu-tically, it is important to rememberthat exercise may cause an increasein systolic pressure and cause hae-morrhaging.

The occupational therapist work-ing with the newly blind individualmust establish effective two-waycommunication and determine thefunctional status of the individual inpreparation for appropriate treat-ment. Starnes Wade (1978) andTrombly and Scott (1977) offer spe-cific assessment and treatment sug-gestions for the blind client. Also, thetherapist should do a home evalua-tion on this client's living accommo-dations and refer the c lient to thenearest Canadian National Institutefor the Blind.

f) StressStress has an affect on blood glu-cose levels (Schade and Eaton,

1983). Emotional stress may lead toglycosuria. In glycosuria there is anexcess amount of glucose in theurine, thereby, giving untrue urineglucose levels. Alternatively, hostileand emotional stress may lead toimmediate elevations in plasma glu-cose and ketone body concentra-tions. Excess ketone bodies may leadto ketoacidosis. Ketoacidosis or dia-betic coma is a result of prolongeduncontrolled diabetes; and it iscaused by an inadequate supply ofinsulin, which prevents the bodyfrom using blood sugar for energy

The Occupational Therapist counselsdiabetics and their families on the way

activity and recreation affect the controlof diabetes.

February/Fvrier 1987 3

7/28/2019 54.1Andrew

4/5

CJOT Vol. 54 N o. 1(Ranch and McWeeny, undated). Inplace of glucose, the body begins toburn fat in an uncontrolled manner,which results in a build up of ke-tones. Symptoms of ketoacidosis in-clude excessive urination, thirst,dehydration, flushed skin, nausea,blurred vision, and fruity odor to thebreath. Ketoacidosis is treated withinsulin and fluids. Hospitalization isnecessary unless the condition is re-versed in the early stages.

Stress can have a profound effecton the long-term prognosis for theclient. If the client's blood sugarscontinue to fluctuate as a result ofstress, then it will become very diffi-cult to medically stabilize this client.It is particularly important to estab-lish a positive therapeutic milieu,because if the health care team can-not manage the psychological state,then it will be very difficult tomanage the blood sugars of the client(Hunt, 1986). The occupational ther-apist should provide a supportivetherapeutic environment. The thera-pist must firstly establish a goodrapport with the patient. Once rap-port is established, the therapistshould be sensitive to the client'smoods and attitudes and provideencouragement and support. Thediabetic should be made aware ofhow stress affects his diabetes con-trol. This education may be providedby the family physician or therapistdepending on your facility.

To assist the diabetic in copingwith his stress the occupational ther-apist can provide stress managementcounselling and relaxation training.Weinstein, Conry and Veidhardt(1982) provide a practical approachto stress management through gen-eral health and well being, personalplanning and communication skills,and manuals on the following relax-ation methods quieting, autogen-ics and progressive relaxationtraining. There are several textbookswritten on stress management andrelaxation, however this author hasfound the above text to be a verygood step-by-step guide to which thepatient can refer while receiving in-struction on these techniques fromthe therapist.

Adaptive Aids for theDiabetic Patient

After an extensive literaturesearch, it was found that there is alimited variety of adaptive aidswhich are available for the diabeticpatient to assist him in self-adminis-tration of insulin. These devices maybe obtained from agencies such asthe Canadian Diabetic Associationor CNIB. Boyles (1977) documentedsix devices which depend on a per-son's senses of touch and hearingrather than sight to administer hisown insulin. Villeneuve, McVey, andSteinberg (1983) discuss educationof a blind diabetic in self-care tech-niques, with particular regards toself-administering of insulin andself-monitoring of glucose levels.Also, for the blind diabetic thereexists a Talking Home Glucose Mon-itoring Machine which reads the glu-cose level aloud.

The "Medi-Jector" is a mechanicalpen-like device which is designed forthose people who have psychologicaldifficulty in giving themselves aninjection. The prescribed dosage ofinsulin penetrates the skin via anultrafine stream that is one-third thesize of the thinnest needle.

"Sleep Sentry" is an insulin reac-tion (hypoglycemia) warning device.This device, similar to a wristwatch,can be worn when sleeping, and issensitive to changes in skin tempera-ture and perspiration two signsthat are commonly seen in a hypo-glycemic state. The drop in skin tem-perature or increase in perspirationwill sound off an alarm, awakeningthe diabetic to take the appropriatemeasure.

One of the most commonly usedmethods by the handicapped, suchas those who are blind, have de-creased hand dexterity, orhemiparesis, is that of pre-loadedsyringes (J. Tyson, personal com-munication, 1985). The syringes canbe loaded and kept in the fridge forup to two weeks. The occupationaltherapist should be aware of theavailable adaptive aids, and educatethe diabetic patient appropriately.(See Appendix for suppliers)

ConclusionIn conclusion, a global overview

of diabetes has been presented. TheDiabetic Day Care at Lions GateHospital and the occupational ther-apist's unique role in the programwere reviewed. As a result of earlierdetection of diabetes and long-termsurvival of diabetics, there is an everincreasing number of people diag-nosed as having this disease. Conse-quently, it is important that occupa-tional therapists be aware of thephysiological aspects of diabetes andhow they affect treatment planning.Equally important is an awarenessof the multitude of secondary com-plications associated with diabetesand their implications in treatment.Some of the adaptive aids availablefor the disabled diabetic were alsoreviewed in the paper. Diabetes isa classic example where lifestyle ad-justment is an important componentof disease management. Theoccupational therapist can offerunique and individualized treatmentprograms that will assist the patientin making these lifestyle changes.

APPENDIXLIST OF MEDICAL SUPPLIERS

Derata CorporationMedi-Jector II7380 32nd Avenue NorthMinneapolis, Minnesota 55427Phone: 1-800-328-3074Sanode LimitedTalking Home Glucose Monitoring Ma-chine3120 Glen Erin DriveMississauga, Ontario L5L IR6Phone: (416) 828-2320Teledyne AvionicsSleep SentryP.O. Box 6098Charlottesville, Va 22906OR FOR ALL OF THE ABOVE ITEMS:Meier Medical Supplies11495 212th St.,Maple Ridge. B.C. V2X 4Z4Phone: (604) 467-3644

REFERENCE LISTAndrew. M.A. (1985). Exercise: The practicalaspects. Reach, 9, 4.Boyles, V.A. (1977). Injection aids for blinddiabetic patients. American Journal of

Nursing, 77, 1456-1458.

14 ebruary/Fvrier 1987

7/28/2019 54.1Andrew

5/5

Brown, M., & Towne, S. (1977). Diabeticperipheral neuropathy: review of literatureand case study. Physical Therapy. 57, 166-169.

Cantu, R.C. (1980). Toward Fitness: GuidedExercises For Those With Health Problems.New York: Human Sciences Association.

Diabetic Day Centre Manual, (1984) MedicalDay Centre, Lions Gate Hospital, NorthVancouver, B.C.Ellenberg, M. (1983). Diabetic neuropathy. InM. Ellenberg and H. Rifkin (eds.), DiabetesMellitus: Theory and Practice. New HydePark: Medical Examination PublishingCo., Inc.

Gossage, J. (1984). How to care for your feet.Reach. 8, 28-29.

Guyton, A.C. (1982). Human Physiology andMechanism of Disease, 3rd Ed. Toronto:W.B. Saunders Co.

Hunt, J.A. (1986). Unpublished Lecture re:Stress and Diabetes.Jette, D:U., (1984). Physiological effects ofexercise in the diabetic. Physical Therapy,64 , 339-342.

Nemchik, R. (1983). Diabetic retinopathy thecurrent status of therapy. RN. 46, 35-37.Policy Manual. (1984) Medical Day Centre,Lions Gate Hospital, North Vancouver,B.C.Ranch, J. & McWeeny, M. (undated) Manag-

ing Your Diabetes. Scarborough: Eli LillyCanada Inc.

Ross, H. Bernstein, G., & Rifkin, H. (1983).Relationship of Metabolic control of dia-betes mellitus to long-term complications.In M. Ellenberg and H. Rifkin (Eds.),Diabetes Mellitus: Theory and Practice. Pp .907-908. New Hyde Park: Medical Exami-nation Publishing Co., Inc.

Schade, D.S. & Eaton, R.P. (1983). Hormonalinterrelationships. In M. Ellenberg and H.Rifkin (Eds.), Diabetes Mellitus: Theoryand Practice. New Hyde Park: MedicalExamination Publishing Co. Inc.

Schumann, D. (1983). Diabetes mellitus andexercise: application of research to activityplanning. Nurse Practitioner. March, 13-20,Occupational Therapy. Pp. 476-481. Phila-delphia: Lippincott Co.

Starnes Wade, A. (1978). Occupational thera-py for problems with special senses:blindness and deafness. In H. Hopkins andH. Smith (eds.) Willard and Spackman'sTrombley,' C.A., & Scott,; A.D. (1977).Occupational Therapy for Physical Dys-function. Pp. 397-398. Baltimore, The Wil-liams and Wilkins Co.

Villeneuve, M.E., McVey, E., &Steinberg, F.(1983). Self care for the totally blind diabe-tic: it is possible. RN, 46, 38-39.Vranic, M., Horvath, S., & Wahren, J. (1979).

Exercise and diabetes: an overview. Dia-betes. 28, 107-110.

Vranic, M., Kemmer, F.W., Berchtold, P., &Berger, M. (1983). Hormonal interaction

in control of metabolism during exercisein physiology and diabetes. In M. Ellen-berg and H. Rifkin (Eds.), Diabetes Melli-tus: Theory and Practice. Pp. 567-582. NewHyde Park: Medical Examination Publish-ing Co., Inc.

Weinstein, M.S., Conry, R.F., and Neidhardt,E.J. (1982). Stress Management Series,West Vancouver, Western Centre HealthGroup.

RsumCet article va dcrire le programmedu Centre pour diabtiques de l'hpi-tal Lions Gate, ainsi que le rle im-portant de l'ergothrapeute dans ceprogramme. Les processus du diabteou les caractristiques pouvant in-fluencer l'valuation et l'interventionpar le personnel en radaptation se -ront discuts, ainsi que les techniquesde prise en charge d'un mode de viepermettant de favoriser le bien-trephysique et psychologique du patient.Le matriel adapt, disponible pourl'administration des mdications, serapass en revue.

Adjust to 1001 positions at the touchwinsof a button.Also has optional built-in massagesullsQueensDual QueenDual King

30"X 80"39"X80"54" x 80"60" x 80"2 (30"X80")2 (39"X80")

Occupational Therapy Professionals recommend Ultramatic Sleep of CanadaElectric Adjustable Beds for their patients (no hospital look). For Price Lists write2289 Fairview Street, Unit 316, Burlington, Ontario L7R 2E3 or callToll Free 1-800-263-6632. We ship and set up anywhere in Ontario.

t o w^el"rr CJOT Vol. 54 No. 1

February/Fvrier 1987 5